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Archive for October, 2010

Endocrine System

October 21, 2010 Leave a comment

Endocrine system

  1. A child with diabetic ketoacidosis has a potassium level of 3 mEq/L. What must the nurse do before giving this client the supplemental potassium ordered by the physician?
    • 1   –   Check the client’s respiratory rate.
    • 2   –   Order another potassium level test.
    • 3   –   Check the nasogastric (NG) tube drainage.
    • 4   –   Check urine output.

    RATIONALE: Before administering potassium to a client, the nurse should assess the urine output because potassium is excreted by the kidneys. The respiratory rate is of no concern when administering potassium. A follow-up potassium level should be drawn after the potassium is administered. NG tube drainage need not be checked before administering potassium.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  2. A client has a subtotal thyroidectomy and is returned from the postanesthesia care unit. Immediate postoperative care would include assessing which of the following conditions to identify a major complication of this procedure?
    • 1   –   Wound for drainage
    • 2   –   Quality of muscle tone
    • 3   –   Client’s position in bed
    • 4   –   Quality of the client’s voice

    RATIONALE: One of the major complications of thyroid surgery is damage to the laryngeal nerve, and the best way to assess for this complication is to evaluate the quality of the client’s voice. Assessing the wound drainage, muscle tone, and client position wouldn’t yield information about a major complication.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  3. A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
    • 1   –   Indwelling urinary catheter kit
    • 2   –   Tracheostomy set
    • 3   –   Cardiac monitor
    • 4   –   Humidifier

    RATIONALE: After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client’s bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. This client doesn’t need a humidifier.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Knowledge

  4. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn’t comply with treatment, which complication may arise?

    • 1   –   Cerebral edema
    • 2   –   Hypovolemic shock
    • 3   –   Severe hyperkalemia
    • 4   –   Tetany

    RATIONALE: Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk of cerebral edema. Hypovolemic shock results from severe fluid volume deficit; in contrast, SIADH causes excessive fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn’t alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn’t occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  5. A client is evaluated for type 1 (insulin-dependent) diabetes mellitus. Which client comment correlates best with this disorder?

    • 1   –   “I’m thirsty all the time. I just can’t get enough to drink.”
    • 2   –   “It seems like I have no appetite. I have to make myself eat.”
    • 3   –   “I have a cough and cold that just won’t go away.”
    • 4   –   “I notice pain when I urinate.”

    RATIONALE: Classic signs and symptoms of diabetes mellitus are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive appetite). Decreased appetite, lingering cough and cold, and pain on urination aren’t related to diabetes. Decreased appetite reflects a GI disorder; cough and cold indicate an upper respiratory problem; and pain on urination suggests a urinary tract infection.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  6. A client visits the physician’s office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves’ disease. Based on the client’s history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by:
    • 1   –   dry, waxy swelling and abnormal mucin deposits in the skin.
    • 2   –   protruding eyes and a fixed stare.
    • 3   –   wide, staggering gait.
    • 4   –   more than 10 beats/minute difference between the apical and radial pulse rates.

    RATIONALE: Exophthalmos is characterized by protruding eyes and a fixed stare. Dry, waxy swelling and abnormal mucin deposits in the skin typify myxedema, a condition resulting from advanced hypothyroidism. A wide, staggering gait and a differential between the apical and radial pulse rates aren’t signs of thyroid dysfunction.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  7. A client who was diagnosed with insulin-dependent diabetes mellitus 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client’s blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
    • 1   –   Cool, moist skin
    • 2   –   Rapid, thready pulse
    • 3   –   Arm and leg trembling
    • 4   –   Slow, shallow respirations

    RATIONALE: This client’s abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of a fluid volume deficit, such as decreased blood pressure, rapid respirations, and a rapid, thready pulse. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations - not slow, shallow ones - are associated with hyperglycemia.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  8. A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to” phrase should the nurse add?

    • 1   –   Related to bone demineralization resulting in pathologic fractures
    • 2   –   Related to exhaustion secondary to an accelerated metabolic rate
    • 3   –   Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
    • 4   –   Related to tetany secondary to a decreased serum calcium level

    RATIONALE: Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn’t accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn’t associated with tetany.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  9. A client with Addison’s disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:
    • 1   –   calcium and phosphorus abnormalities.
    • 2   –   chloride and magnesium abnormalities.
    • 3   –   sodium and chloride abnormalities.
    • 4   –   sodium and potassium abnormalities.

    RATIONALE: In Addison’s disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn’t regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn’t affect levels of these electrolytes directly.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  10. A client with diabetes mellitus has just been prescribed insulin. When teaching the client about hypoglycemia, which of the following effects should the nurse warn the client to expect?
    • 1   –   Polyuria, fatigue, and headache
    • 2   –   Nervousness, diaphoresis, and confusion
    • 3   –   Polydipsia, pallor, and irritability
    • 4   –   Polyphagia and flushed, dry skin

    RATIONALE: Signs and symptoms of hypoglycemia include nervousness, diaphoresis, and confusion. Headache, dizziness, irritability, weakness, pallor, seizures, and coma may also occur. Polyuria, polydipsia, polyphagia, and weight loss are classic manifestations of hyperglycemia, not hypoglycemia. Other signs and symptoms of hyperglycemia include mental status changes, fatigue, blurred vision, and flushed, dry skin.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  11. A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. The client’s urine output suddenly rises above 200 ml/hour 36 hours later, leading the nurse to suspect diabetes insipidus. Which of the following laboratory findings support the nurse’s suspicion of diabetes insipidus?
    • 1   –   Above-normal urine and serum osmolality levels
    • 2   –   Below-normal urine and serum osmolality levels
    • 3   –   Above-normal urine osmolality level, below-normal serum osmolality level
    • 4   –   Below-normal urine osmolality level, above-normal serum osmolality level

    RATIONALE: In diabetes insipidus, polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn’t cause above-normal urine osmolality or below-normal serum osmolality levels.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  12. A client with type 1 (insulin-dependent) diabetes mellitus has just learned she’s pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which of the following guidelines should the nurse provide?
    • 1   –   “Insulin requirements don’t change during pregnancy. Continue your current regimen.”
    • 2   –   “Insulin requirements usually decrease during the last two trimesters.”
    • 3   –   “Insulin requirements usually decrease during the first trimester.”
    • 4   –   “Insulin requirements increase greatly during labor.”

    RATIONALE: Maternal insulin requirements usually decrease during the first trimester because of rapid fetal growth and maternal metabolic changes. This decrease necessitates adjustment of the client’s insulin dosage. Maternal insulin requirements continue to fluctuate throughout the pregnancy. After decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish because of the extreme maternal energy expenditure.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

  13. A client with type 1 (insulin-dependent) diabetes mellitus is admitted to an acute care facility with diabetic ketoacidosis (DKA). To correct this acute diabetic emergency, which measure should the health care team take first?

    • 1   –   Initiate fluid replacement therapy.
    • 2   –   Administer insulin.
    • 3   –   Correct DKA.
    • 4   –   Determine the cause of DKA.

    RATIONALE: The health care team initiates fluid replacement therapy first to prevent or treat circulatory collapse caused by severe dehydration. Although DKA results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won’t circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of DKA are important steps, but the client’s condition must be stabilized first to prevent life-threatening complications.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  14. A nurse is caring for a client with Addison’s disease. Which nursing diagnosis is most appropriate for this client?

    • 1   –   Risk for infection
    • 2   –   Excess fluid volume
    • 3   –   Urinary retention
    • 4   –   Hypothermia

    RATIONALE: Addison’s disease decreases the production of all adrenal hormones, compromising the body’s normal stress response and increasing the risk for infection. Other appropriate nursing diagnoses for a client with Addison’s disease include Deficient fluid volume and HyperthermiaUrinary retention isn’t appropriate because Addison’s disease causes polyuria.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  15. After a physical examination, a 50-year-old client is tentatively diagnosed with Addison’s disease. Which of the following tests would confirm or refute this diagnosis?

    • 1   –   Plasma and urinary cortisol levels
    • 2   –   Blood urea nitrogen and creatinine levels
    • 3   –   Electrolytes and complete blood count
    • 4   –   Chest X-ray and urinalysis

    RATIONALE: Adrenal function is evaluated by examining cortisol levels in plasma and urine. The other diagnostic tests would be part of a general physical examination to assess renal, respiratory, and hematologic status.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  16. An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:
    • 1   –   thyroid storm.
    • 2   –   cretinism.
    • 3   –   myxedema coma.
    • 4   –   Hashimoto’s thyroiditis.

    RATIONALE: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto’s thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Comprehension

  17. During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands secrete parathyroid hormone (PTH). PTH maintains the balance between calcium and:
    • 1   –   sodium.
    • 2   –   potassium.
    • 3   –   magnesium.
    • 4   –   phosphorus.

    RATIONALE: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn’t affect sodium, potassium, or magnesium regulation.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  18. For a client with Graves’ disease, which nursing intervention promotes comfort?
    • 1   –   Restricting intake of oral fluids
    • 2   –   Placing extra blankets on the client’s bed
    • 3   –   Limiting intake of high-carbohydrate foods
    • 4   –   Maintaining room temperature in the low-normal range

    RATIONALE: Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Analysis

  19. On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

    • 1   –   Hypocalcemia
    • 2   –   Hyponatremia
    • 3   –   Hyperkalemia
    • 4   –   Hypermagnesemia

    RATIONALE: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn’t directly cause abnormal serum sodium, potassium, or magnesium levels. Hyponatremia may occur if the client inadvertently received too much fluid; however, the same can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia are usually associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  20. The client has suffered a closed head injury in a snowboarding accident. The client’s urinary output has been 2,000 to 4,000 ml/day. A secondary diagnosis of diabetes insipidus has been made. DDAVP, a synthetic vasopressin, has been ordered as part of the treatment. This medication is usually administered:
    • 1   –   rectally.
    • 2   –   intrathecally.
    • 3   –   I.V.
    • 4   –   intranasally.

    RATIONALE: DDAVP is sprayed intranasally several times each day to control symptoms. The other routes of administration are inappropriate.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  21. The mother of a preschooler recently diagnosed with type 1 (insulin-dependent) diabetes mellitus makes an urgent call to the pediatrician’s office. She says her child had an uncontrollable temper tantrum while playing and now is lethargic and hard to arouse. The nurse should instruct the mother to take which action first?
    • 1   –   Obtain a urine sample and measure the glucose level.
    • 2   –   Force the child to drink orange juice.
    • 3   –   Measure the child’s blood glucose level.
    • 4   –   Call 911, because this is an emergency.

    RATIONALE: In a child with type 1 (insulin-dependent) diabetes mellitus, behavioral changes may signal hypoglycemia or hyperglycemia; measuring the blood glucose level is the only way to determine which condition is present. Urine glucose measurement doesn’t accurately reflect the current blood glucose level. Forcing a lethargic child to drink fluids could cause aspiration. After measuring the child’s blood glucose level, the mother may need to take additional emergency measures, such as administering insulin or a simple glucose source. If the child doesn’t respond to these measures, she may need to call for emergency help.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  22. The nurse expects a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) to have an elevated serum glucose level. Which of the following laboratory findings should the nurse also anticipate?
    • 1   –   Elevated serum acetone level
    • 2   –   Serum ketone bodies
    • 3   –   Serum alkalosis
    • 4   –   Decreased serum potassium level

    RATIONALE: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperglycemic, hyperosmolar state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  23. The nurse is assessing a client with Cushing’s disease. Which of the following observations should the nurse report to the physician immediately?
    • 1   –   Pitting edema of the legs
    • 2   –   Irregular apical pulse
    • 3   –   Dry mucous membranes
    • 4   –   Frequent urination

    RATIONALE: Because Cushing’s disease causes aldosterone overproduction, which increases urinary potassium loss, the disease may lead to hypokalemia. Therefore, the nurse should report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician immediately. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn’t associated with Cushing’s disease.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  24. The nurse is teaching a client with type 1 (insulin-dependent) diabetes mellitus how to manage adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate; however, this treatment isn’t always possible or safe. Therefore, which alternate treatment should the nurse advise the client to keep on hand?
    • 1   –   Epinephrine
    • 2   –   Glucagon
    • 3   –   50% dextrose
    • 4   –   Hydrocortisone

    RATIONALE: During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can’t ingest an oral carbohydrate. Epinephrine isn’t a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and, therefore, isn’t effective in reversing hypoglycemia.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  25. The nurse should expect a client with hypothyroidism to report which of the following health concerns?
    • 1   –   Increased appetite and weight loss
    • 2   –   Puffiness of the face and hands
    • 3   –   Nervousness and tremors
    • 4   –   Enlarged thyroid gland

    RATIONALE: Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves’ disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  26. The parents of a 6-year-old child recently diagnosed with diabetes mellitus are preparing for discharge home. The diabetes resource nurse has been teaching the parents how to administer insulin. To avoid lipodystrophy from occurring, the nurse must teach the parents to:

    • 1   –   rotate injection sites frequently.
    • 2   –   give two separate injections to avoid giving too much in one site.
    • 3   –   let the child select the injection site.
    • 4   –   use the abdomen exclusively.

    RATIONALE: Rotating sites ensures that changes in the subcutaneous fat resulting from insulin administration won’t occur. Giving two injections wouldn’t address the development of lipodystrophy. Letting the child have choices is good, but the parents should give only two options and then have the child choose. Using the abdomen exclusively could cause damage to the subcutaneous layer, thereby altering absorption.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  27. The physician diagnoses type 1 (insulin-dependent) diabetes mellitus in a client who has classic manifestations of the disease and a random blood glucose level of 350 mg/dl. In addition to dietary modifications, the physician prescribes insulin. Initially, most clients receive the least antigenic form of insulin. Therefore, the nurse expects the physician to prescribe which of the following types of insulin?
    • 1   –   Beef insulin
    • 2   –   Fish insulin
    • 3   –   Human insulin
    • 4   –   Pork insulin

    RATIONALE: Human insulin is the least antigenic form of insulin because its composition is identical to that of endogenous insulin. Animal insulins, such as beef, fish, and pork insulins, differ in composition from endogenous insulin and, therefore, are more antigenic.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

  28. To correct a client’s long-term hypothyroid condition, Synthroid or Cytomel may be ordered. When administering the drug, the nurse should be aware that:
    • 1   –   The larger the dose, the more quickly the client will feel better.
    • 2   –   The client will need to take the drug for 6 months to improve.
    • 3   –   Hypothyroid states should be corrected slowly because the body needs time to adjust.
    • 4   –   The time of administration and the dosage amount aren’t relevant.

    RATIONALE: A hypothyroid state must be corrected slowly because a correction made too rapidly may result in angina, arrhythmias, or myocardial infarction. Large doses don’t necessarily make the client feel better more quickly, and the improvement in symptoms may take 2 to 3 weeks. The dosage amount is relevant to the client response.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  29. Typical findings in a client with hypothyroidism include: (Select all that apply.)

    • 1   –   Cold intolerance
    • 2   –   Diarrhea
    • 3   –   Dry skin
    • 4   –   Brittle hair
    • 5   –   Tachycardia
    • 6   –   Slowed speech

    RATIONALE: Clinical findings in acquired hypothyroidism include cold intolerance, dry skin, brittle hair, and slowed speech. There are numerous other symptoms, such as constipation, bradycardia, lethargy, fatigue, weight changes, and menstrual disorders; however, diarrhea and tachycardia aren’t among them.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Comprehension

  30. When administering insulin, where should the nurse administer it so that it will be absorbed most quickly?

    • 1   –   Abdomen
    • 2   –   Arm
    • 3   –   Leg
    • 4   –   Buttocks

    RATIONALE: Insulin is absorbed most rapidly when administered in the abdomen. It’s absorbed more slowly in the arm and leg unless the client exercises vigorously after administration. Absorption is slowest from the buttocks.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Knowledge

  31. When assessing a client with pheochromocytoma, the nurse is most likely to detect:
    • 1   –   Blood pressure of 130/70 mm Hg
    • 2   –   Blood glucose level of 130 mg/dl
    • 3   –   Bradycardia
    • 4   –   Blood pressure of 176/88 mm Hg

    RATIONALE: Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn’t associated with the other options.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  32. When assessing a client with syndrome of inappropriate diuretic hormone (SIADH), a nurse should be aware that which of the following signs suggests that the client is experiencing complications?
    • 1   –   Tetanic contractions
    • 2   –   Neck vein distention
    • 3   –   Weight loss
    • 4   –   Polyuria

    RATIONALE: SIADH causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by neck vein distention. This syndrome isn’t associated with tetanic contractions. SIADH may cause weight gain and fluid retention (secondary to oliguria).
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  33. When assessing a pregnant client with diabetes mellitus, the nurse is alert for signs and symptoms of a vaginal or urinary tract infection. Which of the following conditions makes this client more susceptible to such infections?
    • 1   –   Electrolyte imbalances
    • 2   –   Decreased insulin needs
    • 3   –   Hypoglycemia
    • 4   –   Glycosuria

    RATIONALE: Glycosuria predisposes the pregnant diabetic client to vaginal infections (especially candidiasis) and urinary tract infections because the hormonal changes of pregnancy affect the pH of the vagina and increase the glucose concentration in urine. Electrolyte imbalances and hypoglycemia aren’t associated with vaginal or urinary tract infections. Insulin requirements may decrease in early pregnancy; however, as the client’s food intake improves and maternal and fetal glycogen stores increase, insulin requirements also rise.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  34. Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
    • 1   –   Imbalanced nutrition: More than body requirements related to thyroid hormone excess
    • 2   –   Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing
    • 3   –   Disturbed body image related to weight gain and edema
    • 4   –   Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

    RATIONALE: In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. These changes put the client at risk for marked nutrient and calorie deficiency, making Altered nutrition: Less than body requirements the most important nursing diagnosis. The first option would occur with weight gain or obesity, not with weight loss. The second and third options may be appropriate for a client with hypothyroidism, which slows the metabolic rate.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Analysis

  35. Which of the following outcomes indicates that treatment of a client with diabetes insipidus has been effective?

    • 1   –   Fluid intake is less than 2,500 ml/24 hours.
    • 2   –   Urine output measures more than 200 ml/hour.
    • 3   –   Blood pressure measures 90/50 mm Hg.
    • 4   –   The heart rate is 126 beats/minute.

    RATIONALE: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued fluid deficit, suggesting that treatment hasn’t been effective.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

 

Renal and Urinary System

October 21, 2010 Leave a comment

Renal and urinary system

  1. A client in acute renal failure is admitted to the nephrology unit. The period of oliguria in clients with this condition usually lasts about 10 days. Which of the following assessments of kidney function would the nurse make during the oliguric phase?
    • 1   –   No urine output because the kidneys would be in a state of suppression
    • 2   –   Urine output of 30 to 60 ml/hour
    • 3   –   Urine output of less than 400 to 600 ml in 24 hours
    • 4   –   Urine output that would be directly related to the amount of I.V. fluids infused

    RATIONALE: The three phases of acute renal failure are the oliguria phase (less than 400 to 600 ml of urine produced in 24 hours), diuresis, and recovery. The kidneys aren’t in a state of suppression and won’t achieve an output of 30 to 60 ml/hour. The amount of output isn’t related to the amount of I.V. fluids infused because glomerular filtration rate is decreased.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

  2. A client with chronic renal failure is admitted to the hospital. The physician orders arterial blood gases to be drawn. Which of the following results should the nurse expect?
    • 1   –   Metabolic alkalosis
    • 2   –   Metabolic acidosis
    • 3   –   Respiratory alkalosis
    • 4   –   Respiratory acidosis

    RATIONALE: In chronic renal failure, the client is unable to excrete acid and his ammonia secretion and sodium absorption are altered. Furthermore, the client is in a chronic state of metabolic acidosis, which is only minimally influenced by medications or dialysis therapy.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  3. A client with three children is admitted for surgical repair of a prolapsed bladder. Because the client is still in her childbearing years, the nurse would find that the client understood the surgeon’s preoperative teaching if the client states:
    • 1   –   “If I should become pregnant again, the birth would be a cesarean delivery.”
    • 2   –   “If I have another child, the procedure may need to be repeated.”
    • 3   –   “This surgery may render me incapable of conceiving another child.”
    • 4   –   “This procedure is accomplished in two separate surgeries.”

    RATIONALE: Because the pregnant uterus exerts a lot of pressure on the urinary bladder, the bladder repair may need to be repeated. This client won’t necessarily have to have a cesarean delivery if she becomes pregnant nor would this procedure render her sterile. This procedure is completed in one surgery.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

  4. A preschool-age child is admitted to the hospital with nephrotic syndrome. Nursing assessment reveals a blood pressure of 100/60 mm Hg, lethargy, generalized edema, and dark, frothy urine. After prednisone (Deltasone) therapy is initiated, which nursing action takes highest priority?
    • 1   –   Monitoring the child for hypertension
    • 2   –   Turning and repositioning the child frequently
    • 3   –   Providing a high-sodium diet
    • 4   –   Discussing the adverse effects of steroids with the parents

    RATIONALE: The child with nephrotic syndrome is at risk for skin breakdown from generalized edema. Because this syndrome typically impairs independent movement, the nurse must turn and reposition the child frequently to help prevent skin breakdown. Frequent turning also helps prevent respiratory infections, which may arise during the edematous phase of nephrotic syndrome. The syndrome typically causes hypotension, not hypertension, from significant loss of intravascular protein and a subsequent drop in oncotic pressure. Dietary sodium should be restricted because it worsens edema. Although the nurse should discuss the adverse effects of steroids with the parents, this isn’t a priority at this time.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  5. After the nurse has completed the preoperative teaching for a client who’s having surgery for an ileal conduit, the client asks the nurse when the ileal conduit can be reversed. The nurse would base an answer on the knowledge that:
    • 1   –   3 months after the bowel has had time to heal, it may be reanastomosed.
    • 2   –   the reversal can be done 3 weeks after antibiotics take effect.
    • 3   –   this procedure is permanent.
    • 4   –   most surgical procedures are reversible.

    RATIONALE: Once an ileal conduit has been created, the conduit is permanent and can’t be reversed. Neither healing time nor antibiotic administration would have any effect the potential for or the success of a reversal of this procedure.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

  6. For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
    • 1   –   Cool, clammy skin
    • 2   –   Distended neck veins
    • 3   –   Increased urine osmolarity
    • 4   –   Decreased serum sodium level

    RATIONALE: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing fluid volume deficit. Cool, clammy skin, distended neck veins, and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  7. The nurse is assigned to care for a new pediatric admission, a 5-year-old child with nephrotic syndrome. Which of the following nursing diagnoses should be added to the child’s care plan?
    • 1   –   Imbalanced nutrition: More than body requirements related to weight gain
    • 2   –   Activity intolerance related to increased use of sedatives
    • 3   –   Disturbed body image related to loss of hair
    • 4   –   Excess fluid volume related to glomerular damage

    RATIONALE: Excess fluid volume related to glomerular damage would be an appropriate nursing diagnosis for this client. The glomerulus is involved in the formation of urine. When the glomerular basement membrane is damaged, the client sustains extensive urinary protein loss that leads to edema. The nutrition status is affected because of the client’s usual lack of appetite. Sedatives aren’t usually prescribed because the child feels lethargic from the disease process. Clients with this disorder gain weight related to fluid accumulation and don’t lose their hair.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

  8. The nurse is recording a client’s complaint of painful urination. When documenting this symptom, the nurse should use which of the following terms?
    • 1   –   Oliguria
    • 2   –   Anuria
    • 3   –   Pyuria
    • 4   –   Dysuria

    RATIONALE: The nurse should document painful urination as dysuria. Oliguria refers to a decrease in the amount of urine excreted; anuria, to a urine output below 100 ml/day; and pyuria, to pus in the urine.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

  9. The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts for 2 consecutive hours: 8 a.m., 50 ml; 9 a.m., 60 ml. Based on these amounts, which action should the nurse take?

    • 1   –   Continue to monitor and record the client’s hourly urine output.
    • 2   –   Notify the physician.
    • 3   –   Irrigate the indwelling urinary catheter.
    • 4   –   Increase the I.V. fluid infusion rate.

    RATIONALE: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client’s output is normal. Beyond continued evaluation, no nursing action is warranted.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  10. When assessing a client with acute renal failure, it’s essential that the nurse is familiar with the phases of acute renal failure. Place the phases of acute renal in the order in which they occur. (Use all the options.)
    • 1   –   Recovery phase
    • 2   –   Initial insult
    • 3   –   Oliguric phase
    • 4   –   Diuretic phase

    RATIONALE: Clients with acute renal failure pass through the phases from initial insult to oliguric phase, diuretic phase, and recovery phase. A small percentage of clients won’t progress beyond the oliguric phase and will progress to end-stage renal disease.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  11. When caring for a client who has a three-way system for bladder irrigation, the nurse should remember to do which of the following in calculating the client’s intake and output?
    • 1   –   Add the amount of irrigant instilled to the amount of catheter drainage.
    • 2   –   Subtract the amount of fluid remaining in the irrigation solution bag from the total output.
    • 3   –   Subtract the amount of irrigant instilled from the amount of catheter drainage to obtain the amount of true urine output.
    • 4   –   Measure the amount of catheter drainage and document it on the client’s chart.

    RATIONALE: The catheter drainage contains urine and irrigating solution; therefore, to accurately determine the amount of urine output, the nurse must subtract the amount of irrigant instilled. The other options wouldn’t accurately determine urine output.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

  12. Which of the following assessment findings would lead the nurse to suspect dehydration in a preterm neonate?
    • 1   –   Bulging fontanels
    • 2   –   Excessive weight gain
    • 3   –   Urine specific gravity below 1.012
    • 4   –   Urine output below 1 ml/hour

    RATIONALE: A urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed fontanels, excessive weight loss, decreased skin turgor, dry mucous membranes, and urine specific gravity above 1.012.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

  13. While providing client teaching, the nurse recognizes that the client on peritoneal dialysis has an understanding of peritonitis when he states:

    • 1   –   I’ll call you immediately if I notice that my dialysate outflow is cloudy.
    • 2   –   It’s normal for my dialysate outflow to be bloody.
    • 3   –   Abdominal pain will occur when I perform my daily dialysis fluid exchanges.
    • 4   –   I have no control over catheter connection site contamination during a dialysis fluid exchange.

    RATIONALE: The major complication of peritoneal dialysis is peritonitis. Its most common cause is contamination of the connection site during an exchange. Peritonitis is manifested by cloudy dialysate outflow, fever, rebound abdominal tenderness, abdominal pain, malaise, nausea, and vomiting. It’s never normal for dialysate outflow to be bloody.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

 

Gastrointestinal System

October 21, 2010 Leave a comment

Gastrointestinal system

  1. A 20-year-old woman has just been diagnosed with Crohn’s disease. She has lost 10 pounds and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?
    • 1   –   Let the client eat as desired during hospitalization.
    • 2   –   Weigh the client daily.
    • 3   –   Ask the client to list what she eats during a typical day.
    • 4   –   Place the client on intake and output (I&O) status and draw blood for electrolyte levels.

    RATIONALE: When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldn’t be permitted to eat as desired. Weighing the client daily, placing her on I&O status, and drawing blood to determine electrolyte levels aren’t part of a nutritional assessment.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

  2. A child, age 9, is admitted to the emergency department with pain in the right lower abdominal quadrant, suggesting appendicitis. To further assess for pain associated with appendicitis, the nurse should examine which region?
    • 1   –   Left lower abdominal quadrant
    • 2   –   Right upper abdominal quadrant
    • 3   –   Left upper abdominal quadrant
    • 4   –   Umbilical area

    RATIONALE: In a child, pain that’s diffuse or centered around the umbilicus may be associated with appendicitis (although the pain may localize later). Pain in the left lower abdominal quadrant is associated with descending and sigmoid colon problems; in the right upper quadrant, with gallbladder disease; and in the left upper quadrant, with pancreatitis.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  3. A client has just undergone a colonoscopy and is brought to the recovery area. Which of the following signs or symptoms would indicate that this client is experiencing a complication of the procedure?
    • 1   –   Increased bowel sounds and diarrhea
    • 2   –   Decreased prothrombin time (PT)
    • 3   –   Decreased bowel sounds progressing to a boardlike abdomen
    • 4   –   Flatulence and diarrhea

    RATIONALE: Inadvertent perforation of the bowel is a possible complication of a colonoscopy. Bowel sounds would decrease, not increase; PT isn’t relevant at this time; and the client wouldn’t have diarrhea.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  4. A client is admitted prior to having a Nissen fundoplication for a hiatal hernia. This client’s care plan would indicate the need to assess for heartburn. Heartburn, the predominant symptom of a hiatal hernia, is caused by:
    • 1   –   gastritis.
    • 2   –   esophagitis.
    • 3   –   reflux of gastric contents into the esophagus.
    • 4   –   reflux of duodenal contents into the stomach.

    RATIONALE: The anatomic problem associated with a hiatal hernia is that the opening in the diaphragm (esophageal hiatus) enlarges and the enlargement permits reflux of gastric contents into the esophagus. Gastritis, esophagitis, and reflux of duodenal contents into the stomach wouldn’t occur in hiatal hernia.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  5. A client is instructed to take magnesium and aluminum with simethicone (Maalox TC) by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?
    • 1   –   It has a slow onset of action.
    • 2   –   It has a short duration of action.
    • 3   –   It has a prolonged half-life.
    • 4   –   It’s highly metabolized.

    RATIONALE: Because of the short duration of action, frequent doses of antacids are needed. Antacids usually provide a rapid to immediate onset of action, don’t have prolonged half-lives, and aren’t highly metabolized.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

  6. A client is returned from the postanesthesia care unit after undergoing a Billroth II procedure for peptic ulcer disease. The client vomits despite the presence of a nasogastric (NG) tube. The nurse should do which of the following first?

    • 1   –   Check the tube and suction apparatus for kinks and proper function.
    • 2   –   Irrigate the tube with 30 ml of sterile water.
    • 3   –   Advance the NG tube another 4 to 5 (10 to 12.5 cm).
    • 4   –   Remove the NG tube and replace it with a larger one.

    RATIONALE: The first priority is to check tube patency and proper function of the suction apparatus. Irrigations are done with normal saline, and the nurse must obtain a physician’s order to irrigate an NG tube after gastric surgery. Advancing the NG tube wouldn’t be an option, but replacing the NG tube may be an option after assessments are complete.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Analysis

  7. A client who has been treated for pancreatitis several times is admitted in an acute phase of the illness. Meperidine (Demerol) is prescribed instead of morphine to alleviate pancreatitis pain because morphine:
    • 1   –   can’t be administered I.V.
    • 2   –   causes hypoglycemia.
    • 3   –   tends to produce spasm of the sphincter of Oddi.
    • 4   –   stimulates the secretion of hydrochloric acid.

    RATIONALE: Morphine causes spasm of the sphincter of Oddi, which would increase the client’s level of discomfort. Morphine can be administered I.V. and doesn’t cause hypoglycemia or stimulate the secretion of hydrochloric acid.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  8. A client with a fecal impaction typically exhibits which of the following clinical manifestations?

    • 1   –   Liquid or semiliquid stools
    • 2   –   Hard, brown, formed stools
    • 3   –   Loss of urge to defecate
    • 4   –   Increased appetite

    RATIONALE: Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don’t pass hard, brown, formed stools, because the stool can’t move past the impaction. These clients typically report the urge to defecate (although they can’t pass stool) and a decreased appetite.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Comprehension

  9. A neonate born several hours ago shows signs of a tracheoesophageal fistula (TEF). During the initial assessment, which of the following does the nurse expect to find?

    • 1   –   Continuous drooling
    • 2   –   Diaphragmatic breathing
    • 3   –   Slow response to stimuli
    • 4   –   Passage of frothy meconium

    RATIONALE: Signs of a TEF include continuous drooling, choking, and coughing, which are especially pronounced during feeding. TEF doesn’t cause diaphragmatic breathing, a slow response to stimuli, or passage of frothy meconium.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  10. After an exploratory laparotomy, a client develops a subhepatic abscess. After the abscess is incised and the drainage cultured, the infecting organism is identified as Bacteroides fragilis. The physician prescribes clindamycin phosphate (Cleocin phosphate), 300 mg I.V. every 6 hours. Before administering the antibiotic, the nurse reviews the client’s medication history to check for possible drug interactions. Clindamycin may enhance the action of:

    • 1   –   neuromuscular blocking agents.
    • 2   –   antiarrhythmic agents.
    • 3   –   anticonvulsant agents.
    • 4   –   beta-adrenergic blocking agents.

    RATIONALE: Clindamycin may enhance the action of neuromuscular blocking agents by preventing neuromuscular transmission. It isn’t known to interact with antiarrhythmics, anticonvulsants, or beta-adrenergic blocking agents.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

  11. After taking an antacid, the client asks the nurse where antacids act in the body. The nurse should tell the client that antacids act in the:
    • 1   –   large intestine.
    • 2   –   esophagus.
    • 3   –   small intestine.
    • 4   –   stomach.

    RATIONALE: The therapeutic action of antacids occurs in the stomach. The anions of an antacid combine with the acidic hydrogen cations secreted by the stomach to form water, thereby increasing the pH of the stomach contents. Increasing the pH and decreasing the pepsin activity provide symptomatic relief from peptic ulcer disease. Antacids don’t act in the large intestine, in the esophagus, or in the small intestine.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  12. An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?
    • 1   –   Encouraging the infant to hold a bottle
    • 2   –   Keeping the infant on bed rest to conserve energy
    • 3   –   Rotating caregivers to provide more stimulation
    • 4   –   Maintaining a consistent, structured environment

    RATIONALE: The nurse caring for an infant with inorganic failure to thrive should maintain a consistent, structured environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  13. As a result of a viral infection, a client develops gastroenteritis. The physician prescribes kaolin and pectin mixture (Kaopectate). The client asks the nurse how soon the medication will take effect. What should the nurse tell the client?
    • 1   –   “Onset is 5 to 10 minutes.”
    • 2   –   “Onset is within 30 minutes.”
    • 3   –   “Onset is within 1 hour.”
    • 4   –   “Onset is within 2 hours.”

    RATIONALE: The onset of action of kaolin and pectin occurs within 30 minutes after oral administration. Duration of action is 4 to 6 hours.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  14. During therapy, the nurse monitors a client receiving clindamycin (Cleocin Phosphate) for pseudomembranous colitis. This serious adverse reaction to clindamycin results from superinfection with which of the following organisms?
    • 1   –   Staphylococcus aureus
    • 2   –   Bacteroides fragilis
    • 3   –   Escherichia coli
    • 4   –   Clostridium difficile

    RATIONALE: Pseudomembranous colitis may result from a superinfection with C. difficile during clindamycin therapy. Clindamycin-induced pseudomembranous colitis isn’t caused by S. aureus, B. fragilis, or E. coli.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  15. Identify the area where a nurse would expect to percuss dullness related to the presence of the liver when percussing a client’s chest.
    • -

    RATIONALE: Percussing certain areas of the chest and abdomen will produce expected areas of dullness, flatness, resonance, and tympany. The liver is percussed in the upper right quadrant of the abdomen under the diaphragm.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

  16. In the client’s care plan, the nurse should include an assessment of which of the following conditions that’s liable to result after abdominal surgery from the surgeon’s handling of the intestines?
    • 1   –   Volvulus
    • 2   –   Intussusception
    • 3   –   Hernia
    • 4   –   Paralytic ileus

    RATIONALE: Clients who’ve undergone abdominal surgery are at risk for paralytic ileus. Volvulus and intussusception may require surgery but aren’t caused by it. Hernias may result from surgery but not from handling the intestines.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

  17. The nurse at a neighborhood clinic receives a call from a woman whose son has severe abdominal pain. The nurse advises the mother to bring her son in to be examined. On arrival, the boy says the pain is suddenly gone and he feels much better and wants to go home. What should the clinic nurse tell his mother?
    • 1   –   “The attack has obviously subsided and your son can go home.”
    • 2   –   “If your son has appendicitis, the appendix may have perforated and he should see the surgeon.”
    • 3   –   “The child has the flu.”
    • 4   –   “The appendix has walled off the infection, and oral antibiotics should treat the problem satisfactorily.”

    RATIONALE: The boy should be examined by a surgeon, because peritonitis may be involved. Many clients experience initial improvement in their comfort level after the appendix perforates, but they become acutely symptomatic shortly thereafter and the condition requires immediate attention. Flu symptoms are commonly respiratory - not gastrointestinal - in nature.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

  18. The nurse is assisting the physician in performing a liver biopsy. In which position will the nurse place the client following the liver biopsy?
    • 1   –   Supine position
    • 2   –   Any comfortable position
    • 3   –   Semi-Fowler’s position
    • 4   –   Right side-lying position

    RATIONALE: After the biopsy, placing the client in the right side-lying position decreases the risk of blood or bile leaking through the puncture site as pressure is placed on the liver by the chest wall. The other options wouldn’t decrease this risk.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  19. The physician has just inserted a central line for total parenteral nutrition (TPN) into a client who has a perforated bowel. The physician asks the nurse to begin infusing lactated Ringer’s solution. Prior to starting the infusion, the nurse should verify which of the following?
    • 1   –   Clarity of the physician’s order for I.V. solution
    • 2   –   Temperature of the solution
    • 3   –   Results of the chest X-ray taken after the insertion of the catheter
    • 4   –   Rate of the I.V. infusion

    RATIONALE: Before any solution is administered via a TPN catheter, correct placement of the line must be verified by a chest X-ray. Checking the physician’s order, the temperature of the solution, and the rate of infusion are necessary, but correct placement is the priority at this time.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  20. The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child?
    • 1   –   Avoiding suctioning unless cyanosis occurs
    • 2   –   Elevating the neonate’s head and giving nothing by mouth
    • 3   –   Elevating the neonate’s head for 1 hour after feedings
    • 4   –   Giving the neonate only glucose water for the first 24 hours

    RATIONALE: Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth. The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonate’s head after feedings or giving glucose water is inappropriate because the neonate must remain on nothing by mouth status.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  21. Twenty-four hours after birth, a neonate hasn’t passed meconium. Noting this, the nurse suspects which of the following conditions?

    • 1   –   Hirschsprung’s disease
    • 2   –   Celiac disease
    • 3   –   Intussusception
    • 4   –   An abdominal wall defect

    RATIONALE: Failure to pass meconium is an important diagnostic indicator for Hirschsprung’s disease. The other options aren’t associated with failure to pass meconium.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  22. Which of the following is the most common assessment finding in a child with ulcerative colitis?
    • 1   –   Intense abdominal cramps
    • 2   –   Profuse diarrhea
    • 3   –   Anal fissures
    • 4   –   Abdominal distention

    RATIONALE: Ulcerative colitis typically causes profuse diarrhea. Intense abdominal cramps, anal fissures, and abdominal distention are more common in Crohn’s disease.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

 

Immune System

October 21, 2010 Leave a comment

Immune system

  1. A 10-month-old child with recurrent otitis media (middle ear inflammation) is brought to the clinic for evaluation. To help determine the cause of the child’s condition, the nurse should ask the parents:
    • 1   –   “Have you noticed a lot of wax in the baby’s ears?”
    • 2   –   “Do you give the baby a bottle to take to bed?”
    • 3   –   “Does water ever get into the baby’s ears while his hair is being shampooed?”
    • 4   –   “Can the baby combine two words when speaking?”

    RATIONALE: In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. If the child takes a bottle to bed and drinks while lying down, fluids may pool in the pharyngeal cavity, increasing the risk of otitis media. Cerumen in the external ear canal doesn’t promote the development of otitis media. However, during shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis externa (external ear inflammation). Persistent fluid in the middle ear may impair language development and hearing; however, a 10-month-old child isn’t expected to combine two words when speaking.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

  2. A 30-year-old client has been treated for a variety of musculoskeletal problems for several years. The clinic physician has diagnosed the client as having systemic lupus erythematosus (SLE). The nurse would include which of the following facts when teaching the client about the new diagnosis?

    • 1   –   SLE is an autoimmune collagen disease that may affect many body systems.
    • 2   –   The cardiovascular system is not involved in this disorder, just the musculoskeletal system.
    • 3   –   The Ritchie Block III laboratory test is the definitive diagnostic tool for SLE.
    • 4   –   Antibiotics are the medication action group most commonly used to treat SLE.

    RATIONALE: SLE is an autoimmune disorder that may affect many body systems. Pericarditis is a common cardiac problem in clients with SLE. No definitive diagnostic tool exists for SLE. Corticosteroids are the medication action group most commonly used to treat SLE.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

  3. A 5-year-old child is being admitted to same-day surgery for a tonsilectomy and adenoidectomy. The nurse should assess for which of the following conditions when admitting a client for this particular procedure?
    • 1   –   Nasal abnormalities
    • 2   –   Recent exposure to any communicable disease
    • 3   –   Immunization history
    • 4   –   The presence of loose teeth

    RATIONALE: Loose teeth may hamper the procedure when the retractor is placed in the mouth. Loose teeth may also be lost or swallowed. The anesthesiologist or surgeon would assess for nasal abnormalities. Exposure to communicable diseases should have been assessed during pre-admission testing. The immunization history isn’t pertinent at this time.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  4. A child, age 3, who has been hospitalized with asthma, is to receive oral theophylline (Aerolate) at home. Before discharge, the nurse teaches the parents about signs and symptoms of theophylline toxicity and the need to report these promptly. Which statement by the parents indicates effective teaching?

    • 1   –   “We’ll report irritability and restlessness.”
    • 2   –   “We’ll report a slow pulse and lethargy.”
    • 3   –   “We’ll report a rash and swelling of the hands and feet.”
    • 4   –   “We’ll report coughing and wheezing.”

    RATIONALE: Theophylline causes bronchodilation by promoting adrenergic activation. Signs and symptoms of theophylline toxicity reflect adrenergic stimulation and include irritability, restlessness, tachycardia, and insomnia. Theophylline may also cause such adverse GI effects as nausea, vomiting, diarrhea, and epigastric pain. Rashes and swelling of the hands and feet aren’t associated with theophylline toxicity. Coughing and wheezing are signs of asthma, not theophylline toxicity.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  5. A client complains of periorbital aching, tearing, blurred vision, and photophobia in his right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil - a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine (Atropisol). Atropine belongs to which drug classification?
    • 1   –   Parasympathomimetic agent
    • 2   –   Sympatholytic agent
    • 3   –   Adrenergic blocker
    • 4   –   Cholinergic blocker

    RATIONALE: Atropine is a cholinergic blocker; it dilates the pupil to relieve discomfort and prevent posterior adhesions.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  6. A client is to receive two different types of eye drops at 9:00 a.m. Which of the following should the nurse consider before instilling the prescribed eye drops?
    • 1   –   Eye drops may change color if the container was opened more than 24 hours ago.
    • 2   –   Wait at least 3 minutes between eye drops if more than one medication is to be administered.
    • 3   –   Eye drops must be refrigerated after opening.
    • 4   –   The nurse should shake the eye drop container just before administration.

    RATIONALE: The nurse should wait at least 3 minutes before administering the second type of eye drops, as the eye can only absorb one drop at a time. Eye drops usually change color when the medication is outdated. Not all eye drop solutions require refrigeration, nor do all require shaking.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  7. A client with a history of pheochromocytoma is admitted to the hospital in an acute hypertensive crisis. To reverse hypertensive crisis caused by pheochromocytoma, the nurse expects to administer:

    • 1   –   phentolamine (Regitine).
    • 2   –   methyldopa (Aldomet).
    • 3   –   mannitol.
    • 4   –   felodipine (Plendil).

    RATIONALE: Pheochromocytoma causes excessive production of epinephrine and norepinephrine, natural catecholamines that raise blood pressure. Phentolamine, an alpha-adrenergic blocking agent given by I.V. bolus or drip, antagonizes the body’s response to circulating epinephrine and norepinephrine, which reduces the client’s blood pressure quickly and effectively. Although methyldopa is an antihypertensive agent available in parenteral form, it isn’t effective in treating hypertensive emergencies. Mannitol, a diuretic, isn’t used to treat hypertensive emergencies. Felodipine, an antihypertensive agent, is available only in extended-release tablets and therefore doesn’t reduce blood pressure quickly enough to correct hypertensive crisis.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  8. A client with acquired immunodeficiency syndrome (AIDS) has been seen to evaluate the effectiveness of his treatment plan. After reviewing the client’s progress, the physician starts the client on indinavir sulfate (Crixivan). The client asks the nurse about the purpose of this drug. The nurse’s best response is:

    • 1   –   “This medication decreases the effectiveness of an enzyme needed for human immunodeficiency virus (HIV) replication.”
    • 2   –   “This medication prevents the virus from entering the cell membrane.”
    • 3   –   “This medication enhances the immune response to the virus.”
    • 4   –   “This medication triggers the production of antibodies in response to the virus.”

    RATIONALE: Indinavir acts to inhibit the effectiveness of the enzyme protease, which is necessary for HIV replication. As a protease inhibitor, this drug doesn’t affect the cell membrane, act as an immune modulator, or trigger the production of antibodies to HIV.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  9. A teenager with status asthmaticus has just been admitted to the unit after being stabilized in the emergency department. The physician has ordered an aminophylline level to be drawn upon admission. The result shows an aminophylline level of 8 mcg/ml. Taking into consideration the laboratory result, the nurse would expect which of the following to happen?
    • 1   –   The dosage of aminophylline should be decreased.
    • 2   –   The dosage of aminophylline would remain as is and compliance should be addressed.
    • 3   –   The dosage of aminophylline should be increased.
    • 4   –   The physician will discontinue aminophylline and begin phenobarbital.

    RATIONALE: The therapeutic level of aminophylline is 10 to 20 mcg/ml; therefore, this client needs more aminophylline to achieve a therapeutic level.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

  10. After being hospitalized for status asthmaticus, a 5-year-old client is discharged with theophylline (Theobid), prednisone (Deltasone), and other oral medications. Two weeks later, when the child comes to the clinic for a checkup, the nurse instructs the mother to keep administering theophylline but to gradually decrease the dosage of prednisone, which will be discontinued. The mother asks why prednisone must be discontinued. How should the nurse respond?
    • 1   –   “Steroids increase the appetite, leading to obesity with prolonged use.”
    • 2   –   “Long-term steroid therapy may interfere with a child’s growth.”
    • 3   –   “The child may develop a hypersensitivity to steroids with continued use.”
    • 4   –   “Prolonged steroid use may cause depression.”

    RATIONALE: Steroids suppress release of adrenocorticotropic hormone (ACTH) from the pituitary gland, stopping production of endogenous hormones by the adrenal cortex. Because prolonged adrenal suppression may cause growth retardation in a child, the duration and dosage of steroid therapy must be kept to a minimum. Steroids also may cause central nervous system effects, such as euphoria, insomnia, and mood swings. Although steroids increase the appetite, this isn’t the reason for limiting their use in children. Steroids are present in the body, so hypersensitivity isn’t a problem. They’re likely to cause euphoria, not depression.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

  11. After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs’ test. What is the purpose of performing this test on a pregnant client?
    • 1   –   To determine the fetal blood Rh factor
    • 2   –   To determine the maternal blood Rh factor
    • 3   –   To detect maternal antibodies against fetal Rh-negative factor
    • 4   –   To detect maternal antibodies against fetal Rh-positive factor

    RATIONALE: The indirect Coombs’ test measures the level of antibodies against fetal Rh-positive factor in maternal blood. Although this test may determine the fetal blood Rh factor, the physician doesn’t order it primarily for this purpose. The maternal blood Rh factor is determined before the indirect Coombs’ test is done. No maternal antibodies against fetal Rh-negative factor exist.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  12. Battery acid accidentally splashes in a mechanic’s eyes. His coworkers irrigate his eyes with water for 20 minutes, and take him to the emergency department of a nearby hospital, where he receives emergency care for corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension) to be instilled into the conjunctival sacs of both eyes. Dexamethasone exerts its therapeutic effect by:
    • 1   –   increasing the exudative reaction of ocular tissue.
    • 2   –   decreasing leukocyte infiltration at the site of ocular inflammation.
    • 3   –   inhibiting the action of carbonic anhydrase.
    • 4   –   producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.

    RATIONALE: Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This decreased infiltration reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Dexamethasone and other anti-inflammatory agents don’t inhibit the action of carbonic anhydrase or produce any type of miotic reaction.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  13. The client is returning to the clinic to have the results of his Western Blot Assay explained. The results are positive; therefore, the nurse should include which of the following statements when discussing results with the client?
    • 1   –   “You have acquired immunodeficiency syndrome (AIDS).”
    • 2   –   “You’re immune to AIDS.”
    • 3   –   “You can’t transmit the virus to others.”
    • 4   –   “Antibodies to the AIDS virus are present in your blood.”

    RATIONALE: The client has been infected with the AIDS virus and, as a compensatory mechanism, his body has produced antibodies. The client may not have AIDS; the client isn’t immune to AIDS; and the client can transmit the virus to others.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

  14. The nurse is reviewing the laboratory results of a client with rheumatoid arthritis. Which of the following laboratory results should the nurse expect to find?
    • 1   –   Increased platelet count
    • 2   –   Elevated erythrocyte sedimentation rate (ESR)
    • 3   –   Electrolyte imbalance
    • 4   –   Altered blood urea nitrogen (BUN) and creatinine levels

    RATIONALE: The ESR test is performed to detect inflammatory processes in the body. However, ESR can be elevated as a result of numerous conditions and the test isn’t specific to rheumatoid arthritis, so the health care professional must view results in conjunction with physical signs and symptoms. Platelet count, electrolytes, BUN, and creatinine aren’t usually affected by the inflammatory process.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  15. The physician prescribes corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to:

    • 1   –   combat inflammation.
    • 2   –   prevent infection.
    • 3   –   prevent platelet aggregation.
    • 4   –   promote diuresis.

    RATIONALE: Corticosteroids are used to combat inflammation in a child with SLE. To prevent infection, the physician would prescribe antibiotics. Aspirin is used to prevent platelet aggregation. Diuretics aren’t indicated in SLE.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  16. When assessing the client with a fever, it’s important for the nurse to recognize that a febrile response occurs in four stages. Place the following febrile stages in the order in which the nurse can expect each to occur. (Use all the options.)
    • 1   –   Flush
    • 2   –   Prodromal
    • 3   –   Defervescence
    • 4   –   Chill

    RATIONALE: During the prodromal phase, a client will have nonspecific complains, such as mild headache, fatigue, muscle aches, and malaise. During the chill phase, the client will experience cutaneous vasoconstriction, pale skin, sensation of feeling cold, and shivering. These symptoms cause the body to reach a new temperature set by the control center in the hypothalamus. During the flush phase, the client will experience a sensation of warmth, cutaneous vasodilation, and a flushing of the skin. The final phase, defervescence, results in sweating and a decrease in body temperature.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  17. When teaching a health class to high school juniors, the community health nurse covers human immunodeficiency virus (HIV) modes of transmission. HIV can be transmitted by: (Select all that apply.)
    • 1   –   Social contact
    • 2   –   Sexual contact
    • 3   –   Airborne contact
    • 4   –   Perinatal contact
    • 5   –   Parenteral contact

    RATIONALE: HIV may enter the body by several routes involving the transmission of blood or body fluids. Direct inoculation during intimate sexual contact, transplacental or postpartum transmission (perinatal contact), transfusion of contaminated blood or blood products (parenteral contact), and sharing contaminated needles (parenteral contact) are the modes of transmission. Twenty years of strong data strongly suggest that social and airborne contact don’t lead to HIV transmission.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

 

Musculoskeletal System

October 21, 2010 Leave a comment

Musculoskeletal system

  1. A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy, as prescribed. The child’s left leg is immobilized in a splint. Which of the following is an appropriate expected outcome for this child?

    • 1   –   “The client will change position with minimal discomfort.”
    • 2   –   “The client will bear weight on the affected limb.”
    • 3   –   “The client will ambulate with crutches.”
    • 4   –   “The client will participate in age-appropriate activities.”

    RATIONALE: To prevent pressure ulcers, the child must turn and change position periodically. However, during the acute phase of osteomyelitis, moving the affected leg may cause extreme pain and discomfort. Therefore, the nurse must support and handle the leg gently during turning and repositioning. Weight bearing is contraindicated because it may cause pathologic fractures. Ambulating with crutches is an inappropriate outcome because the child is restricted to bed rest and the affected leg is immobilized to limit the spread of infection. Participation in age-appropriate activities isn’t a realistic outcome because an acutely ill child isn’t likely to be interested in activities; this outcome would be suitable after the acute disease phase ends.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  2. A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by the client suggests that ice application has been effective?
    • 1   –   “I need something stronger for pain relief.”
    • 2   –   “My ankle looks less swollen now.”
    • 3   –   “My ankle appears redder now.”
    • 4   –   “My ankle feels very warm.”

    RATIONALE: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn’t occur after ice application.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  3. A client was admitted to the critical care unit with multiple fractures (of the left femur, left arm, and left lower leg). The client recovered and was transferred to a step-down unit to continue the recovery process. The nurse should include which of the following as a priority in this client’s care plan?
    • 1   –   Medicating for pain as soon as the client requests
    • 2   –   Monitoring for signs and symptoms of a fat embolism
    • 3   –   Monitoring for signs and symptoms of infection
    • 4   –   Involving family members in client care to facilitate discharge planning

    RATIONALE: Clients with fractures of long bones are at risk for embolism caused by fat globules. Most trauma clients have client controlled analgesia (PCA) pumps when conscious. Infection and discharge planning are concerns but aren’t priorities at this time.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  4. A client who’s 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps?
    • 1   –   Suggesting that she walk for 1 hour twice each day
    • 2   –   Advising her to take over-the-counter calcium supplements twice each day
    • 3   –   Teaching her to dorsiflex her foot during the cramp
    • 4   –   Instructing her to increase milk and cheese intake to 8 to 10 servings per day

    RATIONALE: Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client’s need for calcium supplements. If the client eats a balanced diet, calcium supplements or additional servings of high-calcium foods may be unnecessary.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  5. A client with myasthenia gravis has been admitted for surgery for an unrelated problem. The nurse must take which of the following into consideration when administering the client’s Mestinon (an anticholinesterase agent)?
    • 1   –   The medication should be taken on an empty stomach.
    • 2   –   The medication may be crushed if the client is unable to take a whole pill.
    • 3   –   The medication must be administered on time.
    • 4   –   The medication can be given when the nurse gives the other medications ordered for that client.

    RATIONALE: Mestinon must be given punctually to maintain control of the client’s symptoms, especially the ability to swallow. This medication must also be taken with food and may not be crushed. It must be administered according to the physician’s order - not randomly when the nurse gives the other medications ordered for that client.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  6. An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:
    • 1   –   symmetrical thigh and gluteal folds.
    • 2   –   Ortolani’s sign.
    • 3   –   increased hip abduction.
    • 4   –   femoral lengthening.

    RATIONALE: In a child with a congenital hip dislocation, assessment typically reveals Ortolani’s sign (a palpable or audible “click” that occurs as the hip is moved), asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg’s sign.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  7. At the change of shift, an 18-month-old child is being placed in Bryant’s traction after a fall down a flight of stairs. What position would the child be in for this type of traction?
    • 1   –   Flat in bed with the affected leg extended and wrapped in an ace bandage and traction applied
    • 2   –   Flat in bed with a padded sling under the knee on the affected leg and traction applied
    • 3   –   Both legs at a 90-degree angle with the buttocks off the bed and traction applied
    • 4   –   Affected leg at a 90-degree angle with a skeletal pin inserted in the distal end of the femur and traction applied

    RATIONALE: Bryant’s traction may be used in children weighing 25 to 30 lb (11 to 13.5 kg) to reduce a fractured femur. It’s also used to reduce congenital hip dislocation. Flat in bed with an ace bandage wrap is Buck’s extension; flat in bed with a pad under the knee is Russell’s traction; and traction with a pin or wire is skeletal traction.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Knowledge

  8. During discharge teaching, a client with a fractured toe asks the nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?
    • 1   –   Maintaining proper bone alignment
    • 2   –   Relieving swelling by reducing blood flow to the injury site
    • 3   –   Helping prevent skin maceration at the injury site
    • 4   –   Reducing pain by promoting vasodilation at the injury site

    RATIONALE: Applying ice to the injury site soon after an injury causes vasoconstriction, which helps relieve or prevent swelling and bleeding. The other options are inaccurate descriptions of the effects of ice application.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  9. The nurse admits a new client with a fracture of the right greater trochanter to the orthopedic floor. Included on the nursing assessment form are anatomical illustrations of various bones of the body. Indicate the right greater trochanter on the illustration provided.
    • -

    RATIONALE: The greater trochanter is the major, thick bony process below the neck of the femur.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Application

  10. The nurse should expect to administer which of the following medications to a client with gout?
    • 1   –   aspirin
    • 2   –   furosemide (Lasix)
    • 3   –   colchicine (Colsalide)
    • 4   –   calcium gluconate (Kalcinate)

    RATIONALE: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and, thus, ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn’t indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn’t relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, but not to treat gout.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  11. When administering intramuscular immunizations to a toddler, one of the most important questions to consider when deciding between the vastus lateralis and the gluteus maximus as the injection site is:

    • 1   –   how long the child has been walking.
    • 2   –   whether the medication stings.
    • 3   –   how much the child weighs.
    • 4   –   how many injections the child is getting.

    RATIONALE: A toddler should be walking for 1 year to strengthen the muscle before the gluteus maximus may be used as an injection site. The other options don’t influence the decision.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  12. When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening?

    • 1   –   Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed.
    • 2   –   Listen for a clicking sound as the child abducts the hips.
    • 3   –   Have the child run the heel of one foot down the shin of the other leg while standing.
    • 4   –   Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders.

    RATIONALE: To screen for scoliosis, a lateral curvature of the spine, the nurse has the child stand firmly on both feet with the trunk exposed and examines the child from behind, checking for asymmetry of the shoulders, scapulae, or hips. The nurse then asks the child to bend forward at the hips and inspects for a rib hump, a sign of scoliosis. The nurse would listen for a clicking sound while the child abducts the hips when screening for congenital hip dysplasia. The heel-to-shin test evaluates cerebellar function. Having the child shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve XI.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

 

Neurologic System

October 21, 2010 Leave a comment

Neurologic system

  1. A 15-year-old client recently had infectious mononucleosis and had begun to complain of muscle tenderness. This morning, the client was unable to move either leg and was admitted with the diagnosis of paralysis of unknown etiology. After a review of the history and assessment of symmetrical paralysis, a diagnosis of Guillain-Barre syndrome was made. The most characteristic feature of this syndrome is:

    • 1   –   progressive ascending flaccid paralysis.
    • 2   –   unilateral involvement of the dominant side.
    • 3   –   intermittent paralysis of the lower extremities.
    • 4   –   completely reversible asymmetrical paralysis.

    RATIONALE: Guillain-Barre syndrome is an acute episode of progressive ascending flaccid paralysis. The paralysis is classically symmetrical, and the client’s recovery is usually complete.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

  2. A 16-year-old client received a severe head injury in a motor vehicle accident. He’s admitted to the neurologic unit and subsequently develops neurogenic diabetes insipidus. The physician prescribes vasopressin (Pitressin), 5 units subcutaneously twice a day. When vasopressin is given subcutaneously, it begins to act within:
    • 1   –   5 minutes.
    • 2   –   1 hour.
    • 3   –   2 hours.
    • 4   –   4 hours.

    RATIONALE: When vasopressin is given subcutaneously it begins to act within 1 hour. Its duration of action is 2 to 8 hours.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  3. A 3-year-old child has been diagnosed with lead poisoning. On admission, the child’s blood level concentration of lead was 100 mcg/dl. Which of the following nursing diagnoses would be given priority in the care plan for this child?

    • 1   –   Risk for injury related to lead encephalopathy
    • 2   –   Decreased cardiac output related to impaired membrane permeability
    • 3   –   Ineffective GI tissue perfusion related to ingestion of lead
    • 4   –   Ineffective renal tissue perfusion

    RATIONALE: Because the nervous system is affected by high lead levels, the child is at risk for seizures and permanent effects. Cardiac, nutritional, and renal effects also result from excessive lead ingestion, but these aren’t the priority.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  4. A child with otitis media caused by Haemophilus influenzae is treated with antibiotics. Three weeks later the child is diagnosed with meningitis caused by the same pathogen. How was the organism spread?
    • 1   –   Metastasis
    • 2   –   Vascular dissemination
    • 3   –   Transient inflammatory process
    • 4   –   Ineffective antibiotic syndrome

    RATIONALE: Successful treatment of an infection depends on the type of antibiotic and the length of treatment. If either factor is ineffective, the pathogen invades the bloodstream and can appear in a different area. In metastasis, cancer cells spread from one area to another. An inflammatory process wouldn’t account for the vascular spread of this organism, and there’s no specific syndrome associated with ineffective antibiotic treatment.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  5. A client admitted for a hysterectomy has a secondary diagnosis of Menicre’s disease. Which of the following nursing interventions should the nurse include in the client’s care plan to decrease the effects of tinnitus?
    • 1   –   Reduce the amount of glucose and cholesterol in the diet.
    • 2   –   Encourage the client to listen to the radio with earphones.
    • 3   –   Encourage a weight reduction diet.
    • 4   –   Administer antihypertensive medications as ordered.

    RATIONALE: Listening to the radio with earphones is one way to override the buzzing sound in the ears caused by tinnitus. Diet regulation may affect the occurrence of attacks of Menicre’s but not the effects of tinnitus. The client wouldn’t take antihypertensive medications for this disorder.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

  6. A client had a subarachnoid screw inserted to monitor intracranial pressure (ICP) after a fall from a Ferris wheel. Which of the following assessments would indicate that the client’s condition is improving?
    • 1   –   ICP of 13 mm Hg at 7 a.m.; ICP of 17 mm Hg at 8 a.m.
    • 2   –   Glasgow Coma Scale of 10 at 7 a.m. and 8 a.m.
    • 3   –   ICP of 17 mm Hg at 7 a.m.; ICP of 13 mm Hg at 8 a.m.
    • 4   –   Glasgow Coma Scale of 10 for 2 hours at 7 a.m. and 8 a.m.; ICP of 15 mm Hg for 2 hours at 7 a.m. and 8 a.m.

    RATIONALE: Decreasing, not increasing, ICP indicates improvement in the client’s condition. A Glasgow Coma Scale of 10 for 2 hours wouldn’t be indicative of improvement or worsening, as the baseline Glasgow Coma Scale isn’t available. An ICP of 15 mm Hg or above for a period of time is considered problematic; therefore, the client wouldn’t be considered to be improving.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  7. A client has a circular rash on her leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that she has Lyme disease. Her physician prescribes tetracycline (Achromycin), 500 mg by mouth four times daily. Which instruction should the nurse give the client about self-administration of tetracycline?

    • 1   –   “Take the drug on an empty stomach.”
    • 2   –   “Take the drug with food or milk.”
    • 3   –   “Take the drug with a magnesium-containing antacid to reduce irritability.”
    • 4   –   “Take the drug with an iron supplement.”

    RATIONALE: Tetracycline should be taken on an empty stomach because certain foods, such as dairy products, can bind with the drug, preventing its absorption. Additionally, the drug shouldn’t be taken with supplements containing calcium, magnesium, aluminum, or iron. These substances also bind with tetracycline, preventing its absorption.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

  8. A client has just returned to the unit after having an astrocytoma removed. In what position should the nurse place a client immediately after an infratentorial craniotomy?
    • 1   –   Trendelenburg’s
    • 2   –   Prone
    • 3   –   Flat
    • 4   –   Semi-Fowler’s

    RATIONALE: Clients who’ve had an infratentorial craniotomy must remain flat for 24 hours because elevation of the head of the bed may cause detrimental pressure changes. Trendelenburg’s or prone positions would incur radical pressure changes. Semi-Fowler’s position would be selected if the client had a supratentorial craniotomy.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  9. A client has left-sided paralysis. The clinical term for this condition is:
    • 1   –   monoplegia.
    • 2   –   hemiplegia.
    • 3   –   paraplegia.
    • 4   –   quadriplegia.

    RATIONALE: Hemiplegia refers to paralysis of one side of the body. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; andquadriplegia, to paralysis of all four extremities and, usually, the trunk.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

  10. A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing’s syndrome (hypercortisolism) and chronic obstructive pulmonary disease, the nurse formulates a nursing diagnosis of:
    • 1   –   Risk for deficient fluid volume related to excessive sodium loss.
    • 2   –   Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion.
    • 3   –   Ineffective health maintenance related to frequent hypoglycemic episodes secondary to Cushing’s syndrome.
    • 4   –   Decreased cardiac output related to hypotension secondary to Cushing’s syndrome.

    RATIONALE: Cushing’s syndrome causes tissue catabolism, resulting in thinning skin and connective tissue loss. Along with immobility related to stroke, these factors increase this client’s risk for impaired skin integrity. The exaggerated glucocorticoid activity in Cushing’s syndrome causes sodium and water retention, which in turn leads to edema and hypertension. Therefore, Risk for fluid volume deficit and Decreased cardiac output are inappropriate nursing diagnoses. Increased glucocorticoid activity also causes persistent hyperglycemia, eliminating Altered health maintenance related to frequent hypoglycemic episodes as an appropriate diagnosis.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  11. A client newly diagnosed with migraine headaches is being discharged on propanolol hydrochloride (Inderal), a beta-adrenergic blocker. The nurse would know that the discharge teaching regarding this drug was effective if the client stated that the reason Inderal was ordered was to:
    • 1   –   control the nausea and vomiting associated with a migraine.
    • 2   –   control the dilation of blood vessels to exert an antimigraine effect.
    • 3   –   decrease blood pressure and intracranial pressure (ICP).
    • 4   –   decrease the response to pain and increase level of comfort.

    RATIONALE: Beta-adrenergic blockers, such as Inderal, halt the dilation of blood vessels, which exerts an antimigraine effect. Inderal doesn’t control nausea and vomiting, reduce blood pressure or ICP, or influence the pain response.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacologic and parenteral therapies
    COGNITIVE LEVEL: Analysis

  12. A client with a severe head injury is admitted after a motor vehicle accident. The admitting nurse reviews the emergency department nurse’s notes and finds the client’s Glasgow Coma Scale to be 6. The client is in which of the following neurologic states?

    • 1   –   Coma
    • 2   –   Locked-in syndrome
    • 3   –   Vegetative
    • 4   –   Drowsy but easily aroused

    RATIONALE: On the Glasgow Coma Scale, the highest score of 15 indicates the most responsive and a score of 7 or less is usually classified as coma. Locked-in and vegetative states don’t occur with an acute head injury. A drowsy-but-easily-aroused state would be indicated by a higher Glasgow Coma Scale.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  13. A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?

    • 1   –   Preventing infection
    • 2   –   Ensuring adequate hydration
    • 3   –   Providing adequate nutrition
    • 4   –   Preventing contracture deformity

    RATIONALE: Preventing infection is the nurse’s primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they’re secondary to preventing infection.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  14. A neonate in the nursery has been diagnosed with a neural tube defect (myelomeningocele). The nurse would assess for which of the following as the chief urinary problem associated with this disorder?
    • 1   –   Nephrotic syndrome
    • 2   –   Acute renal failure
    • 3   –   Neurogenic bladder
    • 4   –   Renal calculi

    RATIONALE: The presence of a neurogenic bladder in a neonate with myelomeningocele depends on the level of the neural tube defect. Nephrotic syndrome, renal failure, and renal calculi are rarely associated with this congenital anomaly.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  15. A nurse working the night shift reports that 6 hours after a craniotomy, a client is exhibiting signs of increasing papilledema, which may indicate increasing intracranial pressure. As a result, the nursing care plan would now include assessing for which kind of edema?
    • 1   –   Edema of the trigeminal nerve, causing severe facial pain
    • 2   –   Edema of the optic nerve, causing visual disturbances
    • 3   –   Edema of the brain stem, causing labile blood pressure
    • 4   –   Edema of the meninges, causing meningeal irritation

    RATIONALE: Papilledema is edema of the optic nerve.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  16. A teenage girl has just been diagnosed with epilepsy and has been started on phenytoin (Dilantin). Which information should the nurse teach the client regarding this medication?
    • 1   –   Dilantin effects the efficacy of birth control pills.
    • 2   –   Dilantin may turn her urine orange.
    • 3   –   She should tell her ophthalmologist that she’s taking Dilantin.
    • 4   –   She should decrease the amount of sodium in her diet.

    RATIONALE: Dilantin may affect the efficiency of birth control pills, resulting in an unplanned pregnancy. Dilantin has been known to cause pink-tinged (not orange-tinged) urine in some clients. The client should notify her dentist because Dilantin may cause gingival hyperplasia. No dietary restrictions apply to clients taking Dilantin.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  17. After a head injury, a child experiences enuresis, polydipsia, and weight loss. Based on these findings, the nurse should monitor closely for signs and symptoms of:
    • 1   –   hypercalcemia.
    • 2   –   hyperglycemia.
    • 3   –   hyponatremia.
    • 4   –   hypokalemia.

    RATIONALE: Enuresis, polydipsia, and weight loss suggest diabetes insipidus, a disorder that may result from a head injury that damages the neurohypophyseal structures. Diabetes insipidus places the child at risk for fluid volume depletion and hypokalemia. It doesn’t cause hypercalcemia, hyperglycemia, or hyponatremia.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  18. After a motor vehicle accident, a client is admitted with numerous fractures and a closed head injury. When reading the emergency department nurse’s notes, the nurse reads that the client has Battle’s sign present on the right side of the head. Thus, when seeing the client for the first time, the nurse would expect to find:

    • 1   –   ecchymosis behind or below the right ear.
    • 2   –   bilateral black eyes with no facial fractures.
    • 3   –   eyes deviated to the side of injury.
    • 4   –   decorticate posturing.

    RATIONALE: An area of bruising in this location usually indicates a basal skull fracture. The condition of bilateral black eyes with no facial fracture is usually called raccoon’s eyes. Eyes deviated to the side of injury usually indicates a lesion in the cerebral white matter. Decorticate posturing refers to the position the body may assume when there is injury to the cerebral cortex.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  19. Alzheimer’s disease is the secondary diagnosis of a client admitted with a myocardial infarction. Which of the following nursing interventions should appear on this client’s care plan?
    • 1   –   Perform activities of daily living for the client to decrease frustration.
    • 2   –   Provide a stimulating environment.
    • 3   –   Establish and maintain a routine.
    • 4   –   Try to reason with the client as much as possible.

    RATIONALE: Establishing and maintaining a routine is essential to client care because it decreases extraneous stimuli. The client should participate in daily care as much as possible. Attempting to reason with such clients isn’t successful because they can’t think abstractly.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

  20. An 8-year-old child with suspected meningitis is admitted to the pediatric unit. Which of the following would be the best room assignment for this new client?
    • 1   –   A room with an 8-year-old with a perforated appendix
    • 2   –   A room with a child in sickle cell crisis
    • 3   –   A room with laminar air flow
    • 4   –   A single-bed room to decrease extraneous stimulation

    RATIONALE: A child with meningitis will probably have meningeal irritation, which may predispose the child to seizures. Placing this child in a room with one who has either a perforated appendix or sickle cell crisis would expose the already susceptible roommate to infection. Laminar air flow protects against infection, but wouldn’t help a client who already has an infection.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

  21. An eight-year-old child weighing 66 lb is ordered to receive gentamicin (Garamycin) 6 mg/kg/day in three divided doses for meningitis. How many milligrams of gentamicin will the child receive in a single dose administered every 8 hours?
    • -

    RATIONALE: The nurse should use the following formula to determine the correct dose for the child:
    1 lb = 2.2 kg
    66 lb 9 2.2 = 30 kg
    30 kg x 6 mg = 180 mg 9 3 doses
    180 mg 9 3 doses = 60 mg
    1 dose = 60 mg
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  22. An infant has been admitted with a closed head injury, possibly because of maltreatment. During assessment, which of the following clinical manifestations would the nurse note as an indicator of increased intracranial pressure (ICP) in an infant?

    • 1   –   High-pitched cry
    • 2   –   Presence of generalized tonic-clonic seizures
    • 3   –   Longer periods of alertness
    • 4   –   Low-pitched cry

    RATIONALE: As ICP increases, the child’s cry may change to a high-pitched or shrill cry. The presence of generalized tonic-clonic seizures would be a late indicator of increasing ICP. As ICP increases, the infant would become less, not more, responsive. A low-pitched cry wouldn’t indicate increased ICP.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  23. An infant has undergone surgery to remove a myelomeningocele. To detect increased intracranial pressure (ICP) as early as possible, the nurse should be alert for which of the following postoperative findings?
    • 1   –   Decreased urine output
    • 2   –   Increased heart rate
    • 3   –   Bulging fontanels
    • 4   –   Sunken eyeballs

    RATIONALE: Because an infant’s fontanels remain open, the skull may expand in response to increased ICP. Therefore, bulging fontanels are a cardinal sign of increased ICP in an infant. Decreased urine output and sunken eyeballs indicate dehydration, not increased ICP. With increased ICP, the heart rate decreases.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  24. An unconscious client was admitted with a severe head injury resulting from a motor vehicle accident. To facilitate rehabilitation when the client’s condition allows, the nurse should:

    • 1   –   Maintain his limbs in the position of function.
    • 2   –   Apply restraints to the client’s arms and legs to control spasms.
    • 3   –   Exercise just the arms because the legs maintain their tone longer.
    • 4   –   Notify physical therapy as soon as the physician orders passive range of motion.

    RATIONALE: Maintaining the client’s limbs in the position of function decreases the likelihood of contractures. There’s no evidence that the client is experiencing spasms. The nurse should exercise both arms and legs as long as injuries permit. The longer rehabilitation is delayed, the more difficult it becomes.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  25. The client is ordered haloperidol (Haldol) 1.5 mg b.i.d. as needed for agitation. The nurse is preparing to administer the dose using the available 1-mg tablets. How may tablets will the nurse dispense?
    • -

    RATIONALE: The nurse should calculate the client’s dose using this method:
    (1 mg 9 1 tablet) = (1.5 mg 9 X)
    1X = 1.5
    X = 1.5 tablets
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  26. The daughter of a client admitted with a stroke asks the nurse what caused her mother’s stroke. Which of the following would be the nurse’s best response?

    • 1   –   “A stroke occurs when circulation to part of the brain is interrupted by any of a variety of causes.”
    • 2   –   “Strokes are caused by a cerebral hemorrhage.”
    • 3   –   “Strokes are usually caused by abuse of prescription medications.”
    • 4   –   “A stroke may be the result of a transient ischemic attack.”

    RATIONALE: Strokes can be caused by a variety of conditions, including embolus, thrombus, or different types of bleeds. The cause of this client’s stroke must be determined by diagnostic testing; therefore, any of the other response to the client’s daughter would be inappropriate.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  27. The nurse is assessing an infant for signs of increased intracranial pressure (ICP). What’s the earliest sign of increased ICP in an infant?
    • 1   –   Vomiting
    • 2   –   Papilledema
    • 3   –   Headache
    • 4   –   Increased head circumference

    RATIONALE: Increased head circumference is the first sign of increased ICP in an infant. Vomiting occurs later. Papilledema is a late sign of increased ICP and may not be evident. Because the infant can’t speak, the nurse would have trouble determining if the infant has a headache.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  28. The nurse is caring for a client who’s about to undergo a lumbar puncture to assess for the presence of blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which of the following results would indicate an abnormality?
    • 1   –   The presence of glucose in the CSF
    • 2   –   A pressure of 70 to 200 mm H2O
    • 3   –   The presence of red blood cells (RBCs) in the first specimen tube
    • 4   –   A pressure of 200 to 250 mm H2O

    RATIONALE: The normal pressure is 70 to 200 mm H2O, and pressures over 200 mm H2O are considered abnormal. The presence of glucose is an expected finding in CSF, and RBCs typically occur in the first specimen tube from the trauma caused by the procedure.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  29. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which of the following facts should the nurse include in the teaching plan?
    • 1   –   TIA symptoms may last 24 to 48 hours.
    • 2   –   Most clients have residual effects after having a TIA.
    • 3   –   TIA may be a warning that the client may have a stroke.
    • 4   –   The most common symptom of a TIA is the inability to speak.

    RATIONALE: TIA may be a warning that the client will experience a stroke in the near future. TIA symptoms last no longer than 24 hours and clients usually have complete recovery after TIA. The most common symptom of TIA is sudden, painless loss of vision (not speech) lasting up to 24 hours.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  30. The parents of a child undergoing surgery for a severe closed head injury have just finished speaking with the neurosurgeon. When the nurse asks them if they have questions about anything the physician said, the mother questions what the neurosurgeon meant when he stated that one aspect of their child’s injury was “contrecoup.” The nurse should explain that contrecoup means:
    • 1   –   the point of impact on the skull.
    • 2   –   the point on the skull where the brain collided with it, located opposite the point on the skull where the external impact occurred.
    • 3   –   that the skull was fractured and the brain has been compressed.
    • 4   –   a low-grade subdural hematoma may be forming.

    RATIONALE: The brain responds to the force of injury as it changes shape to adapt to the trauma exerted on it. The point of initial impact on the skull is called coup, and the point on the skull directly opposite the point of initial impact (where the brain collides with the opposite side of the skull) is called the contrecoup. Nothing in this scenario indicates a fractured skull or subdural hematoma formation. Although a skull fracture or subdural hematoma may result from a severe head injury, these injuries aren’t part of the “coup” and “contrecoup” definition.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

  31. When doing a neurologic assessment of a client, the nurse will assess for a consensual response of the client’s eyes. This response would be present if the nurse assesses which of the following reactions?
    • 1   –   The eyes have no extraocular movements.
    • 2   –   The red reflex is present.
    • 3   –   The eyes deviate to the side of stimulation.
    • 4   –   When a light is shown in one eye, that pupil constricts, as does the unstimulated eye.

    RATIONALE: In a neurologically stable client, both eyes constrict when a light is shown in one or the other. This response is called consensual pupils. When eyes have extraocular movements, nystagmus may be diagnosed. The red reflex is a normal response in which the retina glows red when a light is shined on the pupil; it doesn’t refer to consensual response. The eyes don’t deviate to the side of stimulation in consensual response.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

  32. When performing a neurologic assessment on a client, the nurse finds that the client’s pupils are fixed and dilated. What does this assessment of the client’s eyes indicate?
    • 1   –   The client is permanently paralyzed.
    • 2   –   The client is going to be blind as a result of an injury.
    • 3   –   The client probably has meningitis.
    • 4   –   The client has received a significant brain injury.

    RATIONALE: When the client has received an injury to the midbrain, the pupils become fixed and dilated, an ominous sign. Paralysis, blindness, and meningitis have clinical manifestations other than fixed, dilated pupils.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  33. When providing oral hygiene for an unconscious client, the nurse must take which essential action?
    • 1   –   Swab the client’s lips, teeth, and gums with lemon glycerin.
    • 2   –   Clean the client’s tongue with gloved fingers.
    • 3   –   Place the client in semi-Fowler’s position.
    • 4   –   Place the client in a side-lying position.

    RATIONALE: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client’s lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning the tongue with gloved fingers wouldn’t be effective in removing oral secretions or debris in an unconscious client. Placing the client in semi-Fowler’s position would increase the risk of aspiration.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  34. Which of the following tests would the nurse expect to see performed on a client with Guillain-Barre syndrome? Select all that apply.

    • 1   –   Electromyography (EMG) studies
    • 2   –   Lumbar puncture
    • 3   –   Cerebrospinal fluid (CSF) analysis
    • 4   –   Vital capacity
    • 5   –   X-rays of the cervical spine

    RATIONALE: EMG studies show a decreased nerve conduction velocity related to the loss of myelin. Lumbar puncture and CSF results may reveal elevated levels of proteins related to inflammation of the nerve root. Vital capacity findings provide the nurse with information related to the effects of motor weakness of the respiratory muscles. X-rays of the cervical spine aren’t clinically significant diagnostic studies for a client with this condition.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Comprehension

 

Hematologic System

October 21, 2010 Leave a comment

Hematologic system

  1. A client has anticoagulant-induced hypoprothrombinemia. The physician prescribes phytonadione (AquaMEPHYTON), 2.5 mg I.V. as the initial dose. After parenteral administration of phytonadione, blood coagulation factors should increase within:

    • 1   –   1 to 2 hours.
    • 2   –   3 to 8 hours.
    • 3   –   6 to 12 hours.
    • 4   –   12 to 14 hours.

    RATIONALE: Blood coagulation factors should increase within 1 to 2 hours after parenteral administration of phytonadione, and within 6 to 12 hours after oral administration. Bleeding may be controlled in 3 to 8 hours, and a normal PT may be obtained 12 to 14 hours after parenteral administration.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  2. A client is admitted with dehydration caused by nausea, vomiting, and diarrhea as a result of food poisoning. The client is to receive 2,000 ml of normal saline in 10 hours. After the I.V. fluids have been absorbed, which of the following would indicate that the client’s level of hydration has improved?

    • 1   –   Lower hematocrit
    • 2   –   Lower white blood cell (WBC) count
    • 3   –   Lower creatinine
    • 4   –   No further weight loss

    RATIONALE: As the client becomes better hydrated, the level of hemoconcentration decreases, and the hematocrit becomes lower. The WBC results aren’t affected by the level of hydration. Serum creatinine levels may assist in determining whether severe dehydration is present, but a blood urea nitrogen (BUN)-to-creatinine ratio is a better indicator as dehydration usually causes BUN levels to rise more than creatinine levels. The client’s weight wouldn’t be a sensitive enough indicator of hydration status.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

  3. A client is in hemorrhagic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client’s:

    • 1   –   blood pressure.
    • 2   –   hemoglobin value.
    • 3   –   temperature.
    • 4   –   clotting time.

    RATIONALE: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client’s blood pressure. The hemoglobin value reflects red blood cell concentration, not overall fluid status. Temperature and clotting time aren’t directly related to the client’s fluid status.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

  4. A nurse has been asked to grade the degree of dyspnea her client with aplastic anemia is experiencing while ambulating. She walks the client halfway down the hall, and the client stops walking toward his room to catch his breath. Using the chart shown here, what grade should the nurse apply to the client’s dyspnea?
    • 1   –   Grade 1
    • 2   –   Grade 2
    • 3   –   Grade 3
    • 4   –   Grade 4

    RATIONALE: This client scenario describes the client as grade 3, walking a short distance (halfway down the hall) and stopping because of his dyspnea. Grades 1 and 2 dyspnea indicate that the client has ambulated a greater distance and aren’t applicable to this situation. Grade 4 dyspnea would have prevented the client from walking down the hallway at all.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Analysis

  5. A school-age child is admitted to the hospital with a diagnosis of acute lymphoblastic leukemia. The nurse formulates a nursing diagnosis of Risk for infection. Which of the following is the most effective way for the nurse to reduce the child’s risk of infection?
    • 1   –   Implementing reverse isolation
    • 2   –   Maintaining standard precautions
    • 3   –   Requiring staff and visitors to wear masks
    • 4   –   Practicing thorough hand washing

    RATIONALE: Acute lymphoblastic leukemia and its treatment cause immunosuppression. Thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn’t significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client’s risk of infection. Staff and others need not wear masks when visiting the client because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep individuals with known infections out of the client’s room.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  6. Clients with various chronic diseases may receive epoetin alfa (Epogen, Procrit). The action of epoetin alfa is to stimulate:
    • 1   –   production of white blood cells (WBCs).
    • 2   –   production of red blood cells (RBCs).
    • 3   –   the immune system.
    • 4   –   the central nervous system.

    RATIONALE: Epoetin alfa mimics the effects of erythropoietin and functions as a growth factor, stimulating RBC production. Filgrastim (Neupogen) stimulates the production of WBCs. Stimulants for the immune system and central nervous system are separate classifications of drugs that aren’t related to erythropoetics.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  7. The physician has ordered a transfusion of whole blood for a client who had a dissecting abdominal aortic aneurysm repaired. The nurse should do which of the following after the transfusion has been initiated?
    • 1   –   Check the client’s vital signs every half hour.
    • 2   –   Add the total number of milliliters transfused to the intake and output (I&O).
    • 3   –   Discontinue the primary I.V. of dextrose.
    • 4   –   Stay with the client for 15 minutes to assess for any reactions.

    RATIONALE: After transfusion begins, the nurse should stay with the client for at least 15 minutes because this is the most likely time for transfusion reactions to occur. The client’s vital signs are initially checked every 15 minutes. The total number of milliliters transfused would be added to the I&O when the transfusion is completed. Transfusions are preceded by I.V. saline, not dextrose
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  8. The physician orders blood coagulation tests to evaluate a client’s blood clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi. Higher risk is associated with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction (MI). Which test is used to determine a client’s response to oral anticoagulant drugs?
    • 1   –   Bleeding time
    • 2   –   Platelet count
    • 3   –   Prothrombin time (PT)
    • 4   –   Partial thromboplastin time (PTT)

    RATIONALE: PT determines a client’s response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample after calcium ions and tissue thromboplastin are added, and compares this time with the fibrin clotting time in a control sample. Anticoagulant dosages should be adjusted, as needed, to maintain PT at 1r to 2r times the control value. PTT determines the effectiveness of heparin therapy and helps evaluate bleeding tendencies. Roughly 99% of bleeding disorders are diagnosed from PT and PTT values. Bleeding time indicates how long a small puncture wound takes to stop bleeding. The platelet count reveals the number of circulating platelets in venous or arterial blood.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

 

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